1801006064 CASE PRESENTATION

 LONG CASE 

A 50 year old man who is a worker in an ice factory and resident  of Miryalguda came with chief complaints of weakness of right upper limb and lower limb , slurring of speech and deviation of mouth to left side since 5 days (12/03/2023)

 HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 1 month back.

Then he developed weakness of left upper limb and lower  for which he went to the local hospital and the symptoms resolved in 3 days.There he was also diagnosed with hypertension for which he took medication for 20 days and stopped since 10 days.

Now again on 12/03/2023 at morning 4 am he developed weakness of right upper limb and lower limb .He also developed slurring of speech and deviation of mouth towards left.Again he was taken to local hospital and CT scan was done and they referred to our hospital.They came to our hospital on 13/03/2023

No history of vomiting headache giddiness, altered sensorium,neck stiffness, abnormal movements, behavioural abnormalities

PAST HISTORY 

History of fracture to right elbow 30 years ago.

No history of diabetes, Asthma, tuberculosis, epilepsy, chronic kidney disease 

No history of trauma to head 

No history of any surgeries

PERSONAL HISTORY 

Diet Mixed 

Appetite Normal 

Sleep Adequate

Bowel and bladder Regular 

Addictions Alcoholic since 20 yrs and chews Gutka

DAILY ROUTINE 

Before the incident he used to get up around  4am goes for work and come by 9 am and have breakfast and again goes back for work and come back by around 1 pm for lunch and goes back to work and come back home at 9 pm  then he will have his dinner and sleep around 10 pm 

After the incident 

He went for work for 20 days and then stopped doing the work.His strength to do works is decreased

FAMILY HISTORY

  No significant family history 

TREATMENT HISTORY 

Took medication for hypertension (Atenolol and  Amlodipine) for 20 days and stopped since 10 days

GENERAL EXAMINATION 

Patient is conscious coherent and cooperative

Moderately built and nourished

Pallor Absent

Icterus Absent

Cyanosis Absent 

Clubbing Absent 

Generalised lymphadenopathy Absent 

Edema Absent

Vitals 

Temperature Afebrile

Pulse pressure 75 beats per min

Blood pressure 130/70 mm Hg

Respiratory rate 17 cycles per min

GRBS 109mg/dl

SYSTEMIC EXAMINATION 

CENTRAL NERVOUS SYSTEM 

Dominance -Right handed

Higher mental functions

Conscious

Oriented to time place and person

Memory -Immediate, recent and remote 

Slurring of speech 

Cranial nerve examination

I- Olfactory nerve-  sense of smell Normal

II- Optic nerve- 

Visual acuity

Field of vision.        Normal 

Colour vision            normal 

III, IV, VI.                Rt          lft        . 

EOM.                        N.          N

  diplopia.              Absent.  Absent

 nystagmus            absent. Absent

ptosis.                     Absent. Absent

Direct and indirect

Light reflex                   present

V- Masseter, temporalis and pterygoid muscles are normal on both sides.

Corneal reflex, conjunctival reflex present on both sides

VII- - Deviation of mouth to left Upper half of right side and left side of face is normal 

Sensory Taste over any.2/3 rd of tongue present 

VIII-  no hearing loss ,no vertigo

IX- no difficulty in swallowing

X- Vagus nerve -No difficulty in swallowing

XI -sternocleidomastoid contraction present, 

Trapeziu- shrugging of shoulders against resistance present

XII - No deviation of tongue,tongue movements normal ,no fasciculations

Motor system 

Tone              Right.          Left 

Upper limb Increased.  Normal

Lower limb Increased  Normal  power.               Right.      Left

Upper limb       3/5            4/5

Lower limb     3/5             4/5 

Superficial reflxes 

Corneal reflex normal on both sides 

Conjunctival reflex normal on both sides 

Plantar reflex Muted on right side 

https://youtube.com/shorts/zBZt8oAn2pI?feature=share

Deep tendon reflexes                                        Right                     Left 

Biceps      +++                        ++

Triceps.    +++                      ++

Supinator +++                     ++

Knee. Jerk +++                   ++

Ankle jerk   +++                ++

Sensory system 

Spinothalamic.           Rt.      Lft

Crude touch          +      +.    

Pain                              +           +

Temperature                +        +

Posterior column

Fine touch                   +        +

Vibration                     Normal

Cortical

Two point discrimination- able to discriminate 

Tactile localization -able to localise 

Cerebellar  Examination 

Finger nose test-Normal

Heel shin  test -Normal

Finger finger nose test -Normal

 No Dysdiadochokinesia 

No meningeal signs

Examination of spine-Normal

Gait

https://youtube.com/shorts/wWUW-SC2vKI?feature=share 

Deep tendon reflexes Right side

Biceps 

https://youtube.com/shorts/Len1bmONhxo?feature=share 

Triceps 

https://youtube.com/shorts/71yp3BvJ84s?feature=share

Knee jerk 

https://youtube.com/shorts/x59TzodyNRc?feature=share 

Ankle jerk 

https://youtu.be/vQOHvsHVGA8 

Supinator 

https://youtu.be/ELosoZCZdy8

Cerebellar functions 

https://youtu.be/7WV9zclao5M 

https://youtube.com/shorts/QMVnw82LWYY?feature=share 

https://youtu.be/oPMTDqOsJPE

RESPIRATORY SYSTEM 

Inspection:   

Shape of the chest : elliptical 

B/L symmetrical , 

Both sides moving equally with respiration 

No scars, sinuses, engorged veins, pulsations

Palpation:

Trachea - central

Expansion of chest is equal on both side

Tactile vocal fremitus Normal

Auscultation:

 . Normal vesicular breath sounds sounds heard

CARDIOVASCULAR SYSTEM

Inspection : 

Shape of chest- elliptical shaped chest

No engorged veins, scars, visible pulsations 

JVP is not raised

Palpation :

 Apex beat can be palpable in 5th inter costal space medial to mid clavicular line

No thrills and parasternal heaves can be felt

Auscultation : 

S1,S2 are heard

no murmurs

ABDOMINAL EXAMINATION

Inspection - 

  Umbilicus - inverted

  All quadrants moving equally with respiration

  No scars, sinuses and engorged veins , visible. pulsations. 

   Hernial orifices- free.

Palpation -  

soft, non-tender

no palpable spleen and liver

Percussion:Resonant note heard

Auscultation- normal bowel sounds heard

PROVISIONAL DIAGNOSIS  

Cerebrovascular accident with Right hemiparesis .

INVESTIGATIONS 

Anti HCV antibodies rapid - non reactive 

HIV 1/2 rapid test - non reactive

Random Blood sugar - 109 mg/dl

 Fasting blood sugar - 114 mg/dl

Hemoglobin- 13.4 gm/dl

WBC-7,800 cells/mm3

Neutrophils- 70%

Lymphocytes- 21%

Eosinophils- 01%

Monocytes- 8%

Basophils- 0

PCV- 40 vol%

MCV- 89.9 fl 

MCH- 30.1 pg

MCHC- 33.5%

RBC count- 4.45 millions/mm3

Platelet counts- 3.01 lakhs/ cu mm

Peripheral Smear

RBC - normocytic normochromic

WBC - with in normal limits

Platelets - Adequate

Complete Urine Examination

Colour - pale yellow

Appearance- clear 

Reaction - acidic

Sp.gravity - 1.010

Albumin - trace

Sugar - nil

Bile salts - nil

Bile pigments - nil

Pus cells - 3-4 /HPF

Epithelial cells - 2-3/HPF

RBC s - nil 

Crystals - nil

Casts - nil 

Amorphous deposits - absent

Liver Function tests

Total bilirubin - 1.71 mg/dl

Direct bilirubin- 0.48 mg/dl

AST - 15 IU/L

ALT - 14 IU/L

Alkaline phosphatase - 149 IU/L

Total proteins - 6.3 g/dl

Albumin - 3.6 g/dl

A/G ratio - 1.36

Blood urea - 19 mg/dl

Serum creatinine - 1.1 mg/dl

Electrolytes 

Sodium - 141 mEq/L

Potassium - 3.7 mEq/L

Chloride - 104 mEq/L

Calcium ionised - 1.02 mmol/L

ECG

Rate 60 beats per min

Rhythm Regular

MRI 

CONFIRMED DIAGNOSIS:

Cerebrovascular accident with Right sided hemiparesis ,

Acute infarct in posterior limb of internal capsule

Treatment

Tab.ECOSPRIN 

Tab.CLOPITAB 75mg PO/OD 

Tab.Stamlo beta

Physiotherapy of right upper limb and lower limb

-----------------------------------------------------------------------------------------------------------------------------

SHORT CASE 

A 38 year old male , who is a civil engineer by profession and resident of West Bengal came to  OPD with chief complaints of :

             Abdominal pain since 5years

   

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 years ago then he developed abdominal pain  which was sudden in onset and progressive in nature.

Pain occured once in every 3 months in the past 41/2 years but since 6 months he is having pain once in a month.pain  is radiating to the back and dragging type of pain.

It aggravates  on taking alcohol and relieved on medication.

 Since  1 year he  had episodes of vomiting  which was  non bilious ,non projectile and water as content followed by abdominal pain

Associated with weakness and giddiness.

He also complained  of severe weight loss. He was 86 kgs 6 months ago but at present he reduced to 67 kgs.

He also has history of depression for which he is attending psychiatric counselling sessions.

Daily routine: He wakes up at 6am in the morning , gets ready and have breakfast ,go to the office ,completes his work and returns by 5pm  and plays badminton or football and then comes to home ,have dinner at 8pm and goes to bed by 10pm.

PAST HISTORY:

History of trauma to nose in childhood while playing football and is having deviated nasal septum to left side which is not affecting his respiration

Episode of jaundice when he was 12 yrs old

Not a known case of DM, HTN,asthma,TB,epilepsy 

History of appendicectomy when he was 17 yrs old

FAMILY HISTORY: No significant family history.

PERSONAL HISTORY:

DIET- Mixed

APPETITE- Normal. 

SLEEP- inadequate

BOWEL AND BLADDER Regular

ADDICTIONS-

ALCOHOL- 180 ml every day since 20years .He had stopped consuming alcohol from 6 months because it increases the severity of abdominal pain.

SMOKING- 2 packs a day  when he was in college. 1 pack a day from 6 months.

ALLERGIES- no allergies

GENERAL EXAMINATION:

Patient was conscious , coherent ,cooperative 

moderately built and nourished

Vitals:

Temperature - Afebrile

PR :- 80 bpm

RR :-16 cpm

BP :- 110/70 mm Hg

SPO2 :- 98%

Pallor: present

Icterus: absent

Cyanosis: absent

Clubbing: absent

Generalised Lymphadenopathy:absent

Pedal edema:Absent

SYSTEMIC EXAMINATION:

CVS-S1, S2 heard,no murmurs

Respiratory System:-

 BAE- present 

NVBS- heard

Per abdomen:-

 soft , non tender.

CNS- no focal neurological deficits

 

PROVISIONAL DIAGNOSIS

Chronic pancreatitis secondary to alcoholism

INVESTIGATIONS

Hemogram 

Hemoglobin 11.2g/dl

RBC count 4.27 million/mm3 

Platelets 2lakhs /mm3 

Total count 4700/mm3 

Eosinophils 02%

Basophils 00

Neutrophils 64%

Monocytes 02%

Lymphocytes 22%

Liver function tests 

Total  bilirubin 1.53mg/dl

direct bilirubin 0.25 mg/dl

SGOT 42 IU/L

SGPT 72 IU/L

Alkaline phosphatase 1242 IU/L

Total protein 5.8g/dl

Albumin 2.9g/dl

A/G ratio 1.28

Renla function tests 

Urea 25 mg/dl

Urice acid 4.5 mg/dl

Creatinine 0.9mg/dl

Serum electrolyte

 Sodium 136 mEq/L

Phosphorus 3 mg/l

Potassium 3 .6 mEq/l

 Calcium9.2 mg/l

Serum Amylase 172 IU/L Normal 25 to 140 IU/L

Serum Lipase 72 IU/L Normal 13 to 60 IU/L

 CT scan Abdomen

Findings

Bulky head and uncinate process of pancreas with heterogeneous cystic areas within with surrounding mild  fat stranding and fluid.Small calcific focus along anterior surface of body of pancreas.Thin pancreatic body and tail with mildly dilated main pancreatic duct

Treatment 

Inj. Tramadol 1 amp in 100 ml NS OD 

TAB. Thiamine 100mg BD 

IV fluids NS , RL @ 75ml/hr 

Tab. Pantop 40mg OD